RESUMEN
Bladder and ureteral injury are serious iatrogenic complications during abdominal and pelvic surgery but are poorly investigated in the general surgery literature. The objective of this study was to examine rates, trends, and patient and surgical characteristics present in lower urinary tract injuries during gastrointestinal surgery using the Nationwide Inpatient Sample (NIS) database. The NIS database was queried from 2002 to 2010 for gastrointestinal surgery procedures including small/large bowel, rectal surgery, and procedures involving a combination of the two. These were crossreferenced with bladder and ureteral injury using International Classification of Diseases, 9th Revision, Clinical Modification codes. Multivariate regression analysis was used to calculate odds ratios for hypothesized risk factors. From 2002 to 2010, total average rates of bladder injury and ureteral injury were 0.15 and 0.06 per cent, respectively. Small/large bowel procedures had lower annual rates of ureteral (0.05 to 0.07%) and bladder (0.12 to 0.14%) injuries compared with ureteral (0.11 to 0.25%) and bladder (0.27 to 0.41%) injuries in rectal procedures. Presence of metastatic disease was associated with the greatest risk for bladder (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.2) and ureteral (2.2; 1.9 to 2.5) injury in small/large bowel surgery, and for bladder (3.1; 2.5 to 3.9) and ureteral (4.0; 3.2 to 5.0) injury in combination procedures. Injury rates were significantly greater in open surgeries compared with laparoscopic procedures for both bladder injury (0.78 vs 0.26%, P < 0.0001) and ureteral injury (0.34 vs 0.06%, P < 0.0001). The incidence of genitourinary (GU) injury in gastrointestinal surgery is rare, less than 1.0 per cent, and is less than the incidence of GU injury reported in gynecologic surgery. This risk is increased by operations on the rectum and the presence of malignancy.
Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Enfermedad Iatrogénica/epidemiología , Complicaciones Intraoperatorias/clasificación , Complicaciones Intraoperatorias/epidemiología , Uréter/lesiones , Vejiga Urinaria/lesiones , Estudios de Cohortes , Intervalos de Confianza , Bases de Datos Factuales , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Pacientes Internos/estadística & datos numéricos , Clasificación Internacional de Enfermedades , Complicaciones Intraoperatorias/fisiopatología , Laparoscopía/efectos adversos , Laparoscopía/métodos , Laparotomía/efectos adversos , Laparotomía/métodos , Masculino , Análisis Multivariante , Oportunidad Relativa , Análisis de Regresión , Reoperación/métodos , Estudios Retrospectivos , Medición de Riesgo , Resultado del Tratamiento , Estados Unidos/epidemiología , Uréter/cirugía , Vejiga Urinaria/cirugíaRESUMEN
OBJECTIVES: To describe the natural history of postureteroscopic renal stone fragments ≤4 mm based on computed tomography (CT) follow-up. The goal of ureteroscopy is to fragment stones, actively basket and remove fragments larger than 1 mm, and allow the remaining fragments to pass spontaneously. The reality is that smaller fragments may be difficult to extract or may be missed. METHODS: Patients treated with ureteroscopy and holmium laser lithotripsy for urolithiasis by a single surgeon from May 2001 to July 2008 at a tertiary referral center were identified. Patients with residual renal fragments measuring ≤4 mm on initial postoperative CT and at least one additional follow-up CT were included. Outcomes measured were fragment growth and location, stone event (emergency department visit, hospitalization, or additional intervention), and spontaneous fragment passage. RESULTS: Of 330 ureteroscopies, 51 met inclusion criteria. For these patients, the mean follow-up duration was 18.9 months (1.6 years). Among 46 ureteroscopies for calcium-based stones, 9 patients (19.6%) experienced a stone event, 10 patients (21.7%) spontaneously passed their fragments, and the remaining 27 patients (58.7%) retained asymptomatic residual fragments. Among this asymptomatic group, mean fragment sizes were similar at 2.7, 3.3, 3.5, and 3.0 mm at mean follow-up durations of 2.8, 10.2, 16.8, and 33.0 months, respectively. CONCLUSIONS: This study suggests that among patients with postureteroscopic renal stone fragments ≤4 mm, approximately one in five (or 19.6%) will experience a stone event over the following 1.6 years. The remaining patients will either become stone-free via spontaneous passage or retain asymptomatic stable-sized fragments.
Asunto(s)
Cálculos Renales/terapia , Litotripsia por Láser , Ureteroscopía , Adulto , Anciano , Femenino , Humanos , Cálculos Renales/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
Renal cell carcinoma (RCC) has been well described for its frequency to metastasize. Cutaneous facial lesions as the primary presentation of RCC is, however, extremely rare. We present clinical, radiographic, and histologic images of a 40-year-old man who presented with a cutaneous facial lesion that was diagnosed as metastatic RCC after excisional biopsy. A subsequent computed tomography demonstrated a small mass (3.5 × 2.6 cm) in the midpole of the right kidney. Partial nephrectomy with histologic analysis confirmed RCC, clear cell type.
Asunto(s)
Carcinoma de Células Renales/secundario , Neoplasias Faciales/secundario , Neoplasias Renales/diagnóstico , Tomografía Computarizada por Rayos X , Adulto , Biopsia , Carcinoma de Células Renales/diagnóstico , Carcinoma de Células Renales/diagnóstico por imagen , Carcinoma de Células Renales/cirugía , Neoplasias Faciales/diagnóstico , Neoplasias Faciales/cirugía , Humanos , Neoplasias Renales/diagnóstico por imagen , Neoplasias Renales/patología , Neoplasias Renales/cirugía , Masculino , NefrectomíaRESUMEN
OBJECTIVES: Ureteral access sheaths (UASs) are used to facilitate ureteroscopic procedures. Difficulties with use have been reported. Manufacturers have redesigned these devices to ameliorate these problems, including reinforcement of the sheath wall. This study compared reinforced (RUASs) and nonreinforced UASs (NRUASs) of the same manufacturer to determine whether RUASs expedite ureteroscopy and how relevant the reinforced structure is in terms of overall success. METHODS: We prospectively followed up patients undergoing ureteroscopy for urolithiasis with 1 of 2 UASs; the Applied NRUAS and the Applied RUAS. The demographics, operative parameters, and outcomes were assessed. Statistical analysis was performed. RESULTS: A total of 98 UASs were used in 68 male and 30 female patients (47 NRUASs and 51 RUASs). No significant differences were found between the groups in terms of demographic parameters, operative parameters, or successful sheath deployment. The overall success rate for sheath deployment was 95%. A pre-existing stent was significantly associated with successful deployment (P = .004). The sheath-specific limitations included kinking (NRUASs, 10%) and sheath angulation/deformity (RUASs, 21%). The mean follow-up time was 43.4 months; and 93.9% of the patients had radiologic follow-up. No ureteral strictures were noted. CONCLUSIONS: No significant difference was found in the overall success rates between the use of Applied NRUASs and RUASs. The presence of a pre-existing stent was significantly associated with successful sheath deployment. Each UAS design had its own unique limitations, seen with low frequency. Successful sheath use might relate to both the sheath itself and the patient/operative parameters.
Asunto(s)
Ureteroscopios , Adulto , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
OBJECTIVE: We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized. MATERIALS AND METHODS: The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California). RESULTS: Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7% and 9.7% of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3%. Our overall positive surgical margin rate was 3.3%. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8% and 16.7%, respectively. CONCLUSIONS: Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.
Asunto(s)
Competencia Clínica , Laparoscopía/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Robótica/métodos , Estudios de Cohortes , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Estadificación de Neoplasias , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Robótica/educación , Resultado del TratamientoRESUMEN
OBJECTIVE: We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized. MATERIALS AND METHODS: The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California). RESULTS: Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7 percent and 9.7 percent of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3 percent. Our overall positive surgical margin rate was 3.3 percent. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8 percent and 16.7 percent, respectively. CONCLUSIONS: Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Competencia Clínica , Laparoscopía/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Robótica/métodos , Estudios de Cohortes , Invasividad Neoplásica , Estadificación de Neoplasias , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Robótica/educación , Resultado del TratamientoRESUMEN
PURPOSE: The most common approach for nonmuscle invasive urothelial cancers of the bladder is transurethral resection of the bladder tumor, often under regional or general anesthesia. Due to the high rate of recurrence, many such patients experience the potential risks and morbidity of frequent surgical intervention, despite the often slow growth rate and low risk of progression of such tumors. Recent experiences have suggested that some patients with low grade superficial tumors may be treated expectantly. We report on our experience with expectant management of low risk superficial bladder tumors. MATERIALS AND METHODS: We retrospectively evaluated 173 patients with superficial bladder cancer who are currently actively treated at our institution and who have complete clinical information. From this population we identified 22 cases (12.7%) under expectant management for bladder tumors in the last 12 months. Demographic and clinical information on this cohort are described as well as clinical and pathological outcomes, and disease interventions on followup. RESULTS: All patients had a prior history of recurrent low risk (Ta, low grade) bladder tumors. The mean followup was 25 months. Of the 22 patients 8 had no growth, 9 had minimal growth and 5 had moderate growth of their tumors. Fifteen patients have required no intervention, 3 have undergone office fulguration and 4 have undergone repeat transurethral bladder tumor resection. Two men (9%) had evidence of grade progression on followup transurethral bladder tumor resection, and 1 of these men (4.5%) had stage progression (T1 disease). Both men had evidence of moderate tumor growth and suspicious/malignant cytology which resulted in the repeat transurethral bladder tumor resection. Interestingly, these 2 men had a 6 and 11 year history of recurrent Ta, low grade disease before progression and had been under expectant management for 18 and 12 months before progression. Interestingly all smokers had a recurrence during the surveillance period and this represented a 3.3-fold increased rate of recurrence over nonsmokers. CONCLUSIONS: Expectant management of recurrent bladder tumors may be an appropriate option for some patients with a history of Ta, low grade tumors, especially those who are older and with significant medical comorbidities. Such a strategy may avoid potential risks and morbidities associated with frequent, repeat transurethral bladder tumor resection. However, under such an expectant management strategy, patients should remain under careful cystoscopic and cytologic surveillance as there remains some risk for grade and stage progression in this patient population.
Asunto(s)
Carcinoma de Células Transicionales/terapia , Neoplasias de la Vejiga Urinaria/terapia , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/terapia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
We report the case of a 24-year-old Cuban-American man initially presenting with a 1-year history of bilateral testicular pain, subsequently diagnosed as sarcoidosis. The diagnosis was histologically confirmed intraoperatively with excisional biopsy of the right tunica. Genitourinary complaints are a rare initial presentation of this disease. Although therapeutic approaches have varied in published reports, no definitive protocol for treatment has been established. We suggest confirmation of the diagnosis, followed by symptomatic treatment, reserving orchiectomy and steroid therapy for severe, refractory, or disseminated cases.